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CA - IC Refuses Treatment That IMR Found Medically Necessary - Printable Version

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CA - IC Refuses Treatment That IMR Found Medically Necessary - SickOfTheProcess - 04-18-2014

California - I'm in California. IMR overturned IC denial for treatment. A victory for the employee. Or…. Maybe not.

Presented my doctor with a copy of the IMR decision overturning IC original denial. He contacts IC to get authorization for treatment based on the IMR findings. IC continues to deny the treatment request. The only reason my doc resubmitted RFA with a copy of the IMR to the adjuster is to make sure everyone gets paid for the treatment… him, hospital, lab, etc.

How can they legally deny treatment when it was ruled medically necessary via IMR? Now what?



RE: CA - IC Refuses Treatment That IMR Found Medically Necessary - 1171 - 04-18-2014

you won't know if the denial is legal until you get a decision from the WCAB.


RE: CA - IC Refuses Treatment That IMR Found Medically Necessary - California_Help - 04-18-2014

(04-18-2014, 01:40 AM)SickOfTheProcess Wrote: California - I'm in California. IMR overturned IC denial for treatment. A victory for the employee. Or…. Maybe not.

Presented my doctor with a copy of the IMR decision overturning IC original denial. He contacts IC to get authorization for treatment based on the IMR findings. IC continues to deny the treatment request. The only reason my doc resubmitted RFA with a copy of the IMR to the adjuster is to make sure everyone gets paid for the treatment… him, hospital, lab, etc.

How can they legally deny treatment when it was ruled medically necessary via IMR? Now what?

Now you can take them to court. IMR approval cannot be denied by a claims adjuster.

(7) For the failure to authorize services found to be medically necessary by the independent medical review organization in the final determination issued under section 9792.10.6 within either five (5) business days of receipt of the determination, or sooner if appropriate for the employee's medical condition, or five (5) business days from the date the determination is final, if an appeal of the determination has been filed under Labor Code section 4610.6(h): $1,000.00 for each day up to a maximum of $5,000.00.

https://www.dir.ca.gov/t8/9792_12.html

]Do you have an attorney?

If you are pro-per you should file for an expedited hearing ASAP and go after the penalty I wrote about above and at a later hearing request a 5814 penalty on top of that. I would also let the insurance carrier know you will be filing for penalties on this at a later hearing.

This is absolute BS. The claims adjuster is now subject of very large fines for this. IMR approval cannot be overturned by a claims adjuster.

If you have an attorney, I would call him and if you don't have an attorney [/size]call and I &A officer and get their assistance on filing for an expedited hearing. If you are representing yourself you can call the claims adjuster and state she is non compliant with IMR and you will be requesting all penalties including 5814.However you cannot request penalties at expedited hearing but can request another hearing for penalties at a later date not to exceed two years after the event.

http://www.workcompcentral.com/wiki/index.php/California_Labor_Codes_5814

If you really want to stop this sort of BS, read my post below about the upcoming meeting about 5814 penalty, and contact your local representative and tell them you support these bills. It takes a 2 minute phone call. If all injured workers started to do this, we would have a much better system. AB2604 increases 5814 penalties to insurance companies who illegally delay benefits to injured workers. Before this bill it was 25% or up to 10 thousand dollars penalty whatever was LESS, this bill changes the penalty to whatever is MORE. This bill is VERY important. If you make a phone call to the chair of the insurance commission (916)319-2031 and tell him you support AB2604 it will help us all.

You can also offer support of this bill to the current chair of the insurance commission, which is Assemblymen Henry Perea District 31.
P.O. Box 942849, Room 3120, Sacramento, CA 94249-0031; (916) 319-2031


RE: CA - IC Refuses Treatment That IMR Found Medically Necessary - 1171 - 05-02-2014

http://www.dir.ca.gov/DIRNews/2014/2014-38.pdf


RE: CA - IC Refuses Treatment That IMR Found Medically Necessary - kev_b - 05-02-2014

(05-02-2014, 02:04 PM)1171 Wrote: http://www.dir.ca.gov/DIRNews/2014/2014-38.pdf
That's for IBR (Independent Billing Review) and not the IMR.